The following case of injury of the abdomen, sent to me by Dr. Rooke, civil surgeon with the army in the field, is very remarkable:—
Robert Cousins, aged 20, 77th Regiment, was admitted into the general hospital, camp, June 8th, with severe injuries caused by a round shot, which struck him when he was on duty in the advanced trenches. When the shot struck him he was standing up, half-face toward the enemy, his right arm extended in front of the right hip; he was in the act of reaching his water-can, which rested against the parapet of the trench.
On admission he was in a state of semi-collapse, the integuments of the right hand and forearm greatly lacerated, the wrist-joint laid open, the bones of the carpus comminuted; the radius and ulna were also fractured at the middle third. There was a lacerated wound in the right iliac region, the size of the palm of the hand; over this space the skin and muscles of the abdominal wall were torn away, the peritoneum lining it was also lacerated, and at the bottom of the wound was seen a coil of intestine in situ; there was no tendency to protrusion, nor were its coats at all injured. The crest and body of the ilium were much comminuted, the fracture extending downward between the anterior superior and anterior inferior spinous processes. The anterior superior spinous process was broken off. There was another wound just below the great trochanter; this apophysis was also shattered. The right limb was two inches shorter than its fellow, the foot everted, but, from the great comminution of the pelvis and the extreme pain produced by examination, it was not satisfactorily made out that the neck of the femur was fractured, but the shortening of the limb and eversion of the foot were in favor of that diagnosis. The injuries which the patient had received were considered mortal; it was thought unnecessary cruelty to amputate the forearm. Such pieces of the ilium as were loose were removed; wet lint applied to the wounds; and brandy and water with opiates were ordered. One of his comrades volunteered to watch over him, and he was left, as all thought, to die. The next day (June 9th) he had partially rallied from the state of collapse; had taken liquid nourishment—beef-tea, arrow-root, etc. There was no pain or tenderness of the abdomen; had passed his water without difficulty. The surface of the abdominal wound was sloughy; intestine still visible; complains of pain in the arm. It was not yet considered advisable to perform any operation. He was ordered opium gr. j every four hours; also a dose of morphia at night, arrow-root, beef-tea, and port wine, which he prefers to brandy.
10th.—Has rallied completely; no pain or tenderness of the abdomen; complains greatly of his arm, and is anxious that something should be done. He slept well after taking the morphia; his face is tranquil, breathing natural, pulse weak; no irritability. Deputy Inspector-General Taylor saw the case in consultation with Dr. Mouat, P. M. O. of the hospital. It was decided to amputate the forearm. This was done at the upper third; chloroform was administered, and produced no ill effects. He was ordered any fluid nourishment he might fancy, with port wine, and an opiate at night.
11th.—No symptoms of peritonitis; suffers no pain; tongue clean and moist; pulse quiet; passes his water regularly; the bowels have not acted. The abdomen is quite soft and fallen, not the slightest tenderness on pressure. To continue on the same plan. He could now give some account of the way in which he was wounded. He stated that he thought it must have been a round shot that struck him. It first struck his arm, then entered the right iliac region, emerging at the lower wound. The surface of the wound in the iliac region is in a sloughy state from the severe bruising of the parts. The coil of intestine is still visible at the bottom of the wound.
12th.—No symptoms of peritonitis; bowels have not acted; tenderness down the outside of the thigh, with redness of the skin, and pitting upon pressure. Stump dressed to-day and looking well.
13th.—No unfavorable constitutional symptoms. The outer part of the thigh is tender and the skin red; free incisions were made; the fascia was sloughy. He takes nourishment; has eight ounces of port wine daily, eggs, arrow-root, and essence of beef. Bowels not acted.
21st.—He had no symptoms worthy of remark since the 13th. The bowels have not been moved; he complained to-day of not being able to pass his motions. Two injections of warm water were administered in the course of the day. He passed a large quantity of hardened feces, which relieved him greatly. The sloughs are separating from the incisions in the thigh; the crest and ala of the ilium are exposed; healthy granulations are springing up from the bottom of the wound. Stump healing favorably.
July 26.—The case has progressed without a bad symptom. At first it was thought that the greater part of the ala of the ilium would exfoliate, but some red points appeared on the surface, and the concavity of the bone became covered with granulations. The exfoliation was limited to the anterior part of the crest of the ilium, which separated on the 17th instant. At various times pieces of bone have been removed as they became detached; there are others still left to come away. The granulations on the upper wound are on a level with the skin of the abdomen. The crest of the ilium is covered with granulations; the wound is contracting, but there is a deficiency of skin to cover the projecting portion of the ilium. The lower wound is also open, and has been enlarged to remove pieces of bone; the incisions in the thigh have healed. The bowels have acted regularly without medicines until to-day, when he required a castor-oil injection. The right thigh is more than two inches shorter than the left; union appears to have taken place; he has no pain on motion. The dead bone that still remains alone prevents the wounds from closing, their surfaces being covered with healthy granulations. His general health is good. He has taken at intervals some oleum jecoris aselli, and, for a mild attack of bronchitis under which he suffered at the end of June, expectorants and diaphoretics. There has not been a single symptom of any abdominal complication. He has an opiate at night. The stump has been healed nearly three weeks.
September 14th.—Since the last report no unfavorable symptoms have occurred. The stump of the forearm has been healed some weeks; his health is good; indeed, from first to last, he has not had a single symptom denoting constitutional disturbance. All the dead bone from the crest of the ilium has separated; the wound of the abdomen is skinned over, with the exception of a small spot about the size of a sixpence. This is healthy, and is gradually healing. The bowels act regularly. There are still two sinuses on the outer side of the thigh—one above, the other below, the great trochanter. On probing these, dead bone is felt, which has not yet separated. The right limb is about three inches shorter than the left, is freely movable in any direction without pain. He can raise the knee from the pillow, but cannot lift the heel from the bed; he can, however, turn himself over on to the left side without assistance. The prominence of the crest of the ilium is greatly diminished from loss of bone. The trochanter major is unusually projecting; the natural appearance of the hip-joint is entirely gone. The injuries to the bones have been so severe, it is difficult to say what changes have occurred. The ilium and pubis have been greatly comminuted, the fracture most probably extending through the acetabulum. Immediately below Poupart’s ligament, to the outside of the femoral artery, a hard substance is felt beneath the skin. This, when he was admitted, was at first supposed to have been a piece of a shell, but it is now thought to be a portion of the pubis driven downward upon the thigh.