Document 37mnamgvEYxdV7Q75bQLxjLKy

From John R. Low-Beer, Esq. New York City Law Department 100 Church Street (Room 3-170) New York, NY 10007 (212) 788-1355 BY MESSENGER TO: David Rosner Program in the History of Public Health and Medicine COLUMBIA UNIVERSITY 110 Haven Avenue TOWER III, Suite 17H New York, NY 10032 (212) 304-7979 m a d e w ith a refined an titoxin or glob u lin , accord in g eith er to th e old or to th e n e w form u la. F r e e z in g o f a th r e e L -j- d o se m ix tu r e o f to x in -a n ti to x in c o n ta in in g 0 .3 p er cen t, tricresol, p rep a red w ith an an titoxin con cen trated w ith ou t the use o f heat, resulted in a n in c re a se in to x icity o f th e m ix tu r e. F reezin g o f m ix tu res o f toxin -an titoxin m a d e w ith u n c o n c e n tr a te d a n tito x in a n d c o n ta in in g th r e e L -fd o s e s o f to x in , in w h ic h tricreso l o r p h e n o l is u se d a s a p r e se r v a tiv e , r esu lts in a n in c r e a se in to x ic itv o f th e m ixtu re. F r e e z in g o f su ch m ix tu r e s in w h ic h c h lo rb u ta n o l or c h lo r o fo r m is u sed as a p reserv a tiv e, or in w h ic h n o p r e se r v a tiv e is u sed , d o e s n o t c a u se a n in c re a se in toxicity o f the m ixtu re. O n ly h ig h ly refined an tito x in or glob u lin sh o u ld b e u sed in th e p rep a ra tio n o f d ip h th eria to x in -a n tito x in m ixtu res. M ix tu re s o f d iph theria toxin -an titoxin con tain in g o n e -te n th L -}- d o s e s sh o u ld b e th e o n ly fo r m u la p erm itted . 195 College Avenue. cl/A L E A D P O I S O N I N G I N C H I L D R E N V W IT H SPECIA L REFEREN CE TO PICA .U Y ' JOHN C. RUDDOCK, M.D. LOS ANGELES P ic a , o r p a r o r ex ia , is a c r a v in g fo r u n n a tu r a l articles o f fo o d -- a d e p r a v e d a p p etite. It h a s b e e n o b se r v e d in h ysteria, ch lorosis, in san ity an d p reg n a n cy , b u t m o re p a rticu la rly a m o n g ch ild ren in th e latter h a lf o f in fa n c y , ch ild ren fro m 1 to 2 yea rs o f age. It so m e tim es b egin s in later c h ild h o o d w h e n fr o m a n y c a u se th e g en era l h ea lth fails, an d th e ch ild b e c o m e s a n em ic. Still 1 states th at h e h a s seen fo u rteen cases. In so m e o f h is cases, m u d a n d m o rta r w e r e esp ecial fa v o r ite s : in o th ers, coal, c in d ers a n d g r a v el w e r e p r e ferred . In n in e cases, th e h ab it b eg a n in th e seco n d v e a r o f lif e ; in o n e , it b e g a n a t 8 m o n th s . T h o m s o n , 12 i n a s t u d y o f p i c a a n d i t s c a u s e s , d i v i d e s th is m o r b id c r a v in g in c h ild re n in to tw o g r o u p s : 1. T h o s e in sta n ces in w h ic h th e h ab it b e g in s at a n y a g e, o fte n asso cia ted w ith so m e m a rk ed d eterioration o f th e g e n e r a l h e a lth (o f w h ic h a n e m ia is u su a lly a s y m p to m ), an d lessen s or p asses off as the gen eral con d ition im proves. 2. A la rg er g r o u p in w h o m th e m o r b id c ra v in g d e v e lo p s in ea rlv in fa n c y , as o p p o rtu n ity fo r its in d u l g e n c e offers, ap art fro m a n y v ery n oticeab le cach ex ia , a n d w i t h o u t a n e m ia , p a s s in g oft" g r a d u a lly in m o s t c a s e s , e v e n if u n tre a te d , w h e n th e ch ild is a b o u t 3 y e a r s old . P a tie n ts in th e fo r m er , or ca ch ectic, class m a y b e s u f ferin g fr o m a variety o f cu rab le an d in cu rab le co n d i tion s, su ch a s rick ets, b ron ch itis, r o u n d w o r m s, a p p a r en tly id iop ath ic an em ia, m align an t tu m or, tu b ercu losis a n d oth er ch ron ic m aladies. K o p lik 3 b e lie v e s th at th is p ecu lia r c o n d itio n in ch il d r e n is an e x a g g e r a tio n o f th e n o r m a l h a b it in y o u n g in fa n ts o f in variab ly p lacin g ev ery th in g w ith in reach in th eir m o u th s. In ch ild ren w h o su ffer fr o m pica, th e se n se o f w h o le so m e n e ss is la ck in g , a n d th e y c ra v e sa n d , 1. Still, G. F .: Common D isorders and Diseases of Childhood, London, H en ry Frow dc, 1915, pp. 779-782. 2. Thom son, John: On Pica, or D irt E ating, in C hildren, E dinburgh H osp. Rep. 3 : 81-94, 1895. 3. Koplik, H e n ry : The Diseases of In fan cy a n d Childhood, Phila delphia, Lea & Febiger, 1918, p. 793. dirt, g ra v el, cin d ers, w all plaster, p ap er, p ain t a n d other su b sta n ces. A lth o u g h a ch ild w ith p ica cra v es m a n y d ifferen t t y p e s o f th in g s , it i< v e r y f o r t u n a t e th a t m o s t o f th e se th in g s a re inert, a n d . a lth o u g h th e y o c ca sio n a llv lead to m in o r ailm en ts, su ch as co n stip a tio n , ftssu re-in -an o a n d o th er intestinal d isord ers, th ey d o n o t ca u se any seriou s d istu rb a n ce o f th e h ealth o f th e ch ild . T h e r e is. h o w e v e r , o n e ty p e o f p o iso n in g w h ic h th ese p ica c h ild ren a cq u ire, a n d th at is lead p o iso n in g . T his m a y easily he o v erlo o k ed , b eca u se th e a v era g e ph ysician h a s n ev er h ad h is a tten tio n called to th e fact, a n d also b e c a u se th e clin ical p ic tu r e is u su a lly v e r y d iffe re n t fr o m th a t in sim ila r p o iso n in g in a d u lts. T h e r e a re m am w a y s in w h ic h th e ch ild m a y a c q u ire lea d p o iso n in g w h ich th e a v era g e p aren t co u ld easily p reven t. S o m e ch ild ren affected w ith pica h a v e a m o rb id cra v in g to g n a w p a in te d o b je c ts, su c h as w in d o w sills, w h ite fu rn itu re, crib railin gs, p o rch ra ilin g s a n d o th er articles a r o u n d th e h o m e w ith in th eir reach . A ch ild liv es in a lead w orld . 1 h ere are m a n y o th er w a y s in w h ic h lea d m a y be in tr o d u ced b y m o u th : in p a in t fr o m to y s ; in b u n s an d ca n d ies co lo red w ith lead c h r o m a te ; in p rin ters' typ e u sed as a p la y th in g ; in o in tm e n t o f lead o x id (lith a rg e ), a n d in w a te r an d m ilk th at h a v e sto o d in lead recep tacles. O r th e ch ild m a y b e c o m e p o iso n ed b y im p ro p er m e d ic a t io n , i. e ., b y t a k in g le a d a c e t a t e s o lu t io n in treatm en t o f p oison o a k ; b y su ck in g p ain t fro m the m oth er's face ; b y n u rsin g after the u se o f lead oin tm en t on the m oth er's breast, or b y sw a llo w in g lead en objects, su ch as B B shot. H o lt 4 rep orted o n e case d u e to in h alation o f dust that co n ta in ed lead. H e also stated th at th e n u m b e r of a u th en tic ca ses o f lead p o iso n in g in y o u n g in fa n ts w a s v ery sm all, a lth ou gh m u ch h as b een w ritten on co n gen ita l lead p o iso n in g in e x te n siv e stu d ies o f th e 1a m ilies o f w o r k e r s in lead , in w h ic h , in m a n y in stan ces, b oth p aren ts w ere su fferin g fro m lead p o ison in g. B efo re tak in g u p the gen eral d iscu ssion an d sy m p to m a to lo g y o f lea d p o iso n in g in c h ild re n , I sh all rep o rt tw o cases, w h ich h ave co m e u n d er m y ob servation d u r in g th e last y ea r ; REPORT OF CASES C ask 1.-- A boy, a g e d 3 y e a r s , n o r m a l a t b i r t h a n d al w a y s well except fur nervousness, caused by irregular sleeping hours and careless parents, lor six months previous to obser vation bad complained of severe abdominal cramps associated with vomiting, loss of weight and appetite, listlessness, irri tability, night cries, bed wetting and progressive anemia. The abdominal cramps were usually in the afternoon and evening, and were becoming more frequent. The child had been observed by several physicians in their offices, and in one instance the diagnosis of appendicitis was made. The correct diagnosis, however, might have been made by any one who called at the child's home, because every bit of paint on porch railings, window- sills, crib, bureau, chairs and even white enameled door casings, as high as the child could reach, had been gnawed off. The child was fairly well nourished, and was pale and pot bellied, hut of normal height. There was a distinct lead line on the gums. The abdomen was relaxed, and no tenderness was elicited. The spleen was just felt. There was no paralysis. The laboratory data were: white blood corpuscles, 15,400; red blood corpuscles, 4.000.000; hemoglobin. 50 per cent. A differential count was normal. There was no stippling, and the red cells showed only the usual evidence of a secondary anemia. Lead was recovered from both the urine and the feces. 4. Holt, L. E., J r .: Lead Poisoning in In fan c y , Am. J . Dis. Child 2 5 : 229 (M arch) 1923. V olume 82 N u m b e r 21 LEAD POISONING--RU D D O CK 1683 As this child would not gnaw varnished objects, it was easy to remove the source of lead by refinishing the entire house; within two weeks, except for some anemia, the child was normal. Cask 2.--A girl, aged 2 years, normally developed, who had always been well, during the last month had had three series of convulsions. The mother stated that the child gnawed the paint from the crib and the window sills, and had an uncon trollable desire to chew any painted object. examination was negative, except for a slight degree of internal strabismus of the left eye, which the mother had not noted before. The red blood corpuscles numbered 4,520,000 per cubic millimeter; the hemoglobin was 60 per cent. Xo stippling was seen. Xo lead was found in the urine, but there were traces of lead in the feces on two examinations. Since the source of lead has been removed, this child has made an uneventful recovery and is now normal. SYM PTOMATOLOGY " T h e h isto r y o f th e c a se is v e r y im p o r ta n t a n d m a y lead to a n e a sy d ia g n o s is a fte r all o th e r m e th o d s h a v e p r o v e d fa ilu re s. T h e a p p e a r a n c e o f th e ch ild is u su a lly strik in g in th e ch ro n ic ca ses o f lead p o iso n in g , on accou n t o f th e d eg ree o f secon d ary a n em ia con com itan t w ith it. In th e e a rly c a ses, a c h a n g e o f d isp o sitio n is o fte n the first s y m p to m n o tic ed . T h e ch ild b e c o m e s fr etfu l, p eevish a n d restless at n ig h t; th e a p p etite b e c o m es p o o r ; the b rea th is fo u l, a n d fr eq u e n tly h e m o r r h a g e s o ccu r fro m th e g u m s . T h e ch ild m a y c o m p la in o f p a in s in th e ep igastriu m a n d th e legs. In c h r o n ic ca ses, th e p a in s in th e a b d o m e n b e c o m e co n tin u o u s a n d m o r e sev ere. C o n stip a tio n is p resen t. V o m itin g is rare. T h e r e is u su a lly a d e g r e e o f a n e m ia p resen t, b u t o c ca sio n a lly th e p a r e n ts o v e rlo o k all m a n i festations u n til th e d ev elo p m en t o f cerebral d istu rb an ces. V ery fe w ca ses rep o rted sh o w th e ch aracteristic w rist d rop so c o m m o n in a d u lts, b u t p a ra ly sis o f th e cran ial nerves, p a rticu la rly th e facial a n d m o to r ocu li n erves, is c o m m o n . G ib s o n 6 r e p o r te d a g r o u p o f e y e s y m p tom s, w h ich h e r eferred to as " p lu m b ic ocu lar n eu ritis." T h e te m p e r a tu r e , a s a ru le, is n o r m a l e x ce p t in th e fatal ca ses a n d in th o se w ith cereb ra l d istu rb a n c es, in w h ic h it m a y r e a c h 1 0 5 o r 1 0 6 F . b e f o r e th e d e a t h o f the patient. O f the variou s fo rm s o f cerebral d isord ers p rod u ced by lead , c o n v u lsiv e se iz u r e is b y fa r th e m o st c o m m o n . I h ere is n o w a y , h o w e v e r , to d istin g u ish th e c o n v u lsio n s due to lead p o iso n in g fro m th ose d u e to other causes. A ll typ es o f c o n v u lsio n s a re seen . T h e y m a y b e local or g e n e ra l; th ey m a y b e m ild or severe. T h e co n v u l sions d o, h o w e v e r , h a v e o n e ch a ra cteristic, a n d th at is that th ey a r e v e r y p e r siste n t a n d a re a tte n d e d b y a h ig n m ortality. folic has b een m o re freq u en tly ob served than para>sis, b u t m o r e c o m m o n th a n e ith e r a r e irr ita b ility , restlessness a n d a b lu e lin e o n th e g u m s. It sh o u ld b e rem e m b e re d , h o w e v e r , th a t a c o n tin u o u s lea d lin e is 'ck lom fo u n d . T h e ch a ra cteristic a p p ea ra n ce is th e presence o f m in u te b la ck d o ts in th e m a r g in o f th e m ucous m em b ra n e a ro u n d the teeth, w h ich are covered " k h tartar. It is d ifficu lt to see, a n d a h a n d len s sh o u ld Used. i lie b lo o d p ic tu r e , e x c e p t fo r a s e c o n d a r y a n e m ia . U sually tells u s n o th in g , a lth o u g h th is is d e te r m in e d b y >e d u r a t i o n o f t h e p o i s o n i n g . I f t h e d i s e a s e h a s b e e n ,1 r,|r '^ complete description of the symptomatology of lead poisoning in A n '^V 'x .^ u `en hv Blackfan. K. D .: Lead Poisonaing in C hildren, ' Sc. 1 3 3 : 877 (Ju n e ) 1917. } ,umi y C " ' J*'. _LL.;: The D iagnosis, Prophylaxis atnd T reatm ent of 2 : P ' u^ar -Neuritis Amongst Q ueensland C hildren, M. J. A ustralia f.,- ^ 1917; On the Im portance of D e-Ionization in the Treat1 Plumbism in Q ueensland C hildren, ibid. 1 : 272 (A pril 5) 1919. p resen t for so m e tim e, stip p lin g o f tb e red b lood corp u scles m a y occur. D irect e v id en ce o f lead p o iso n in g is o b ta in e d b y th e d e m o n s t r a t i o n o f 78 l e a d i n t h e u r i n e a n d f e c e s . T h e r e is, h o w e v e r , a lw a y s a la rg e r a m o u n t in th e fe c e s th a n in th e u r in e , a n d it is o fte n p r e s e n t in th e fe c e s w h e n it c a n n o t b e d e m o n stra te d in th e u rin e. C L A SSIFIC A TIO N IN T O GROUPS B e ca u se o f th e variab ility o f th e sen sitiv en ess o f ch il d ren to lead , a classification in to d efin ite g r o u p s is diffi cult, a n d w h en m a d e m u st be b a sed largely o n th e severity o f the p red om in atin g system . T u r n e r d iv id es lead p o iso n in g in ch ild ren in to fo u r g ro u p s: 1. P aralytic cases sh o w in g sy m m etrica l w rist-d rop , foot-d rop , sp a sm o f the calf m u scles an d , as a secon d ary lesion , a p ersisten t talip es e q u in u s. 2. C a ses ch a ra cterized b y p a in s in th e a b d o m en a n d lim b s, co n co m ita n t w ith h ab itu al co n stip a tio n , a n d o c c a sio n a lly a b lu e lin e o n th e g u m s . T h e se ch ild ren a re u su ally irritable a n d n eu rotic. 3. C h ild ren su fferin g fr o m o cu la r n eu ritis; viz., a n eu ritis in v o lv in g the op tic, o cu lo m o to r, a b d u cen s a n d troch lear n erves. 4. E clam p tic cases w ith severe an d p ersisten t co n v u l sion s, w h ich o fte n en d fatally. W e are in d eb ted to .A u stralian o b serv ers fo r m o st o f th e litera tu re r e g a r d in g lea d p o iso n in g in ch ild re n , a n d to r an historical a cco u n t o f lead p o iso n in g in th e ch il d ren o f Q u e e n sla n d , fr o m th e first rec o r d e d c a se s in 1 8 9 2 t o 1 9 1 7 . A r e c e n t a r t i c l e 7' r e c o r d s t h e p r o b a b l e su ccess o f efforts to h a v e a n act p a ssed p roh ib itin g th e u se o f w h ite lead p ain t o n v era n d a railin gs a n d ou tsid e su rfa ces w ith in th e reach o f ch ild ren 's fingers. TREATM ENT T h e treatm en t o f this con d ition m a y b e con sid ered from three p oin ts o f v iew : 1. P ro p h y la ctic. C a refu l su p erv isio n o f ch ild ren d u r in g th e a g e (fr o m 1 to 3 y e a r s ) in w h ic h p ica is m o st p revalen t. W id e p u b licity an d ed u ca tio n th ro u g h p eriod icals a n d h o m e jo u rn a ls, in o rd er to ed u ca te th e p a r e n ts. 2. S y m p to m a tic. F o r th e sp asm s, ch lo ro fo rm in h ala tio n is th e o n ly a g e n t th a t is e ffic a c io u s; fo r th e a n e m ia , th e v a rio u s fo r m s o f iron a n d a r se n ic; fo r th e local p a l sies, m a ssa g e an d electricity, a n d fo r th e p erm a n en t palsies, su rg ery sh ou ld h e resorted to, if possible. 3. M ed icin al. F o r th e rem o v a l o f lead fro m th e sy stem , p o ta ssiu m iodid, fr o m 3 to 5 g ra in s (0 .2 to 0.3 g m .) th ree tim es d a ily w ith a m o r n in g p u rg e o f m a g n e siu m su lp h a te m a y b e tried . T h is is th e u su a l m e th o d , a lth o u g h in se v e r e c a s e s it is n o t w e ll to g iv e th e iod id s, since, a cco rd in g to so m e w riters, th e lib era tion o f th e lead th at h a s b een d ep o sited in th e tissu es m a y in crease the severity o f th e sy m p to m s. G ib so n .0 in 1919, rep o rted su cc e ssfu l trea tm en t b y the tw o-b ath ionization system . T h e patien t places both h a n d s o n an a lu m in u m p late im m er se d in a salt so lu tion , w h ic h is c o n n e c ted w ith th e n e g a tiv e p o le, a n d b o th feet lik ew ise in a sim ila r h a th , w h ic h is co n n ected w i t h t h e p o s i t i v e p o l e . F r o m 7 1*/U t o 8 1 v o l t s a n d 2 5 7. Considerable urine is evaporated to dryness, and 50 e.c. of fuming nitric acid is added; after the reaction has subsided, it is allowed t simmer over the free flame for one-half hour, and then 25 c.c. more acid is added three times each fifteen m inutes. The fluid is then evapo rated to a small volume, neutralized with sodium hydroxid. filtered and the lead tested with hydrogen sulphid. which will give a brown precipitate. 8. An H istorical Account of the O ccurrence and Causation of Lead Poisoning Among Queensland Children, M. J. A ustralia 1 :1 4 8 (Feb. 11) 1922. 1GU4 I N J U R Y OR R E C T U M --M A R B U R Y J o u r . A. M. A. M ay 24, 1924 m i l l i a m p e r e s o f c u r r e n t g i v e n f o r o n e - h a l f h o u r , d a i l y . truck entered an alley, and crushed between it and the side T h e l e a d i s d e p o s i t e d o n t h e a l u m i n u m p l a t e i n t h e of a brick wall. He was brought soon afterward to the n egative bath. CONCLUSIONS emergency hospital. The pupils were equal and reacted to light and in accommodation. The tongue was coated. The 1 . P i c a i s o n e o f t h e m o s t i m p o r t a n t e t i o l o g i c f a c t o r s teeth and gums were in good condition. The tonsils were in lea d p o iso n in g in ch ild ren . slightly enlarged, but the pharynx was otherwise normal. 2 . '1 h e r e a r e m a n y m i l d c a s e s o f l e a d p o i s o n i n g i n There were several palpable cervical glands. The chest was ch ild ren , m a n ife ste d b y sp a sm s o r colic, th e tru e n a tu re o f w h ich are n ever su spected . 2. E n erg etic p rop h ylactic m ea su res sh ou ld be firm, and expansion was good and equal on the two sides. The percussion note was resonant throughout. The breath sounds were clear. The heart was not enlarged, hut there was a soft systolic murmur at the apex not transmitted to e m p l o y e d w i t h c h i l d r e n w h o h a b i t u a l l y e a t p a i n t e d the axilla. The abdomen a r tic le s . was slightly distended and 4 . T h e f e c e s a n d t h e u r i n e s h o u l d b e e x a m i n e d f o r tender in the region of the l e a d i n a l l c h i l d r e n w i t h c o n v u l s i o n s i n w h i c h t h e bladder. About the rectum, e tio lo g ic fa cto r is n o t clear. running anteriorly, there 1002 Pacific Mutual Building. was a laceration, which seemed to go through the sphincter. There was much bleeding, some of which T R A U M A T I C I N J U R Y O F T H E R E C T U M appeared to come from high REPOKT OF CASE * up in the rectum. An at tempt was made to pass a W. B. MARBURY, M.D. catheter, but this was un successful and only a little WA S H IN G TO N , D. C. blood was obtained. On In lo o k in g o v er th e literatu re, in c lu d in g th at at th e S u r g e o n G e n e r a l 's L i b r a r y , o n i n j u r i e s t o t h e r e c t u m . I h a v e b een u n a b le to find a case sim ilar to th e o n e rep orted here. G an t ep itom izes six ty -fo u r cases that fell u n d e r h is p e r so n a l o b ser v a tio n . T h e s e m a y b e classified a s : further examination it was found that the laceration at the rectum included both sphincters and part of the perineal raphe. The finger could he passed upward anterior to the mucous Fig. 2. -- Muscles being sutured over the rectum en masse; area be tween sutured muscle and skin packed lightly with gauze (.not 1 . T h o s e d u e t o i n j u r y f r o m f o r e i g n b o d i e s , e i t h e r membrane of the bowel, and shown). d u rin g in stru m en ta tio n or as result o f accid en t. A m o n g th ese, fish -h ook s, g u n sh o t w o u n d s, fallin g o n p a lin gs or stab s, an d u se o f th e sp ecu lu m a n d dilators p lay a co n sp icu o u s part. 2. R u p tu re o f the sp h in cter d u e to p ed erasty, or o f the sharp edges of the broken ramus on the right side could be felt. Also the urethra was torn in this region, and urine was passed through the opening. Whenever the patient's legs were moved in any way, he experienced great pain in the region of the symphysis. Once when we were moving the patient, the whole pelvis was t h e p e r i n e u m d u r i n g p a r t u r i t i o n . R u p t u r e o f t h e r e c t o -ceil to rock irregularly, and definite crepitus was obtained. v a g i n a l s e p t u m d u r i n g There was no evidence of injury to the extremities. c o p u la tio n . The patient was sent to the operation room. Under general 3 . R e c t o v a g i n a l r e n t anesthesia, and with the patient in the lithotomy position, a i n d u c e d b y r e c t a l d i s t e n more thorough examination was made. The rectal tube was tion w ith a n air-filled r u b ber bag. 4. P erfo ra tio n o f the rectu m b y fo reig n b od ies left in th e a b d o m en . 5. U lceration d u e to p h en o l ( carb olic a c id ) or tu rp en tin e. found practically intact, hut the muscles anterior to it were torn and retracted on both sides so as to appear only laterally, and retracted far back toward the posterior surface. The rough edges or the fractured descending ramus of the pubes could he felt. The opening in the urethra was not made out. The torn sphincter muscles and the levator ani were brought together over the midline anteriorly and sutured with chromic catgut. This procedure was facilitated by keeping one 'nger in the rectal tube. The area above this was left open, and a T h e a n a t o m i c s t r u c small amount of packing was placed in the space for drainage t u r e s m o s t u s u a l l y a f f e c t and to control oozing. A cast was applied from the knees to e d a r e t h e r e c t u m o r s i g the costal margin. m o i d , u r e t h r a , o n e o r Dr. Groover reported that examination of the lumbar spine, both sp h in cters, the leva Fig. 1.-- Muscles in front of the rectum torn and retracted, with the latter j.radically intact. tor ani m u scle, an d the rectovaginal septum . O n ly in o n e ca se w a s th ere m en tio n o f an y in ju re to the b on y structure, and that w as w h en the coccyx w a s fra ctu re d as th e resu lt o f a k ick d u r in g a fight. T h e u n iq u e featu res ab ou t th e case rep orted h ere are pelvis and hips showed the presence of a dislocation of the right innominate bone, with a fracture of the descending ramus of the pubes on the right side; the pubic symphysis was separated approximately 1 inch and there was, of course, necessarily some compensatory damage in the sacro-iliac joints. The following day the patient seemed a little better, though very restless. There was some abdominal distention, and he complained of the cast being too tight. This was loosened. t h a t a l l t h e m u s c l e s a b o u t t h e r e c t u m w e r e t o r n a n d There was copious drainage of pus from the peroneal wound, r e t r a c t e d , l e a v i n g t h e i n t e s t i n e i n t a c t ; r u p t u r e o f t h e and the temperature rose to 102.2 F. He voided involuntarily u r e t h r a , a n d f r a c t u r e o f t h e d e s c e n d i n g r a m u s o f t h e and through the urethral rent. Two hundred cubic centi p u b es. 1 REPORT OF CASE meters of physiologic sodium chlorid solution was given by hypodermoelysis. August 14, he had an involuntary defeca L. S., a colored boy, aged 4 years, while riding on the tion. He had a frequent desire to urinate by the normal route, running board of a truck, Aug. 11, 1923, was thrown as the but without success. August 28, or seventeen days after admission, there were some signs of the patient's regaining * Read before the Virginia, Maryland and District of Columbia Med ical Society, Dec. 5, 1923. control of the bowels, but the urethral fistula persisted. i