INJURIES OF THE KIDNEY.
Protected as they are, partly by bony walls, and more extensively by the muscles and fascia; constituting the abdominal parietes, le sions of these organs are comparatively rare when wo consider the frequency with which the trunk is exposed to injuries of all kinds. Both civil and military practice will, however, be found to furnish numerous instances and many varieties requiring some classification.
Breaches of surface involving the kidney may be divided into two classes, namely, punctured wounds such as are inflicted by the use of sharp instruments as by stabbing, and contusions and lacerations which for the most part are occasioned by the application to the body of other forces, and are usually unattended with a lesion of the integ uments.
Some rare cases are recorded of hernia of the kidney through a wound in the abdominal wall, of which the following quoted by Filcher (from a report in the Wiener medicinische Wochenschrift, 1873) may be taken as a typical example : CASE.—" June 3d, 1873, S. P., aged 25, was stabbed with a knife Case.—" June 3d, 1873, S. P., aged 25, was stabbed with a knife in the left hypochondrium; two or three hours after a cough set in, which caused the kidney to protrude through the wound. At the end of twenty-four hours he presented himself at the clinic of Professor Brandt, in Klausenbu•g, having a pulse of SO, a temperature nearly normal, and being able to walk to a gallery to be photographed. On the fourth day after being wounded the kidney was drawn out and severed, after its pedicle had been ligatured. Rapid recovery re sulted. At no time did he show symptoms of urfemia or peritonitis. The quantity of urine secreted increased daily while he was under observation. June 23d he left the hospital, able to work as before." Cases of punctured or incised wounds, for instance in the loins in the direction of the kidney as determined by examination either with the finger or a probe, and attended with more or less luematuria and escape of urine by the wound, require treatment on general surgical principles. If the bleeding is considerable, as evidenced by what escapes externally or by the urine passed through the urethra, the wound should be opened up and explored to the bottom and the con dition of the kidney ascertained. Where the injury does not go be yond the kidney hemorrhage may as a rule be arrested by packing the wound with antiseptic gauze around a drainage tube and the ap plication of a wood-wool compress. When the kidney is wounded, for instance, by a bayonet thrust as a soldier is retreating, the organ may be transfixed and the peritoneal cavity opened and filled with blood. If there is reason to believe, either from digital exploration
or from the condition presented by the abdomen, apart from the question of hemorrhage, that this space is invaded, a should be proceeded with in preference to, or even in addition to, the enlargement of the original wound, as it is not unlikely that a perfora tion of the intestine may have also been occasioned. Such a com plicated lesion as this, would necessarily require the removal of the kidney in addition to the closure by suture of the intestinal wound. It must not be forgotten that a stab wound of the kidney is not, as a rule, a fatal injury or one that requires the removal of the organ; whereas, if complicated with a penetration of the intestinal viscera, there is little chance of recovery unless the latter lesion can be ex posed and sutured. I once saw the back of the colon punctured in the course of an operation for exploring the right kidney. The wound, being a very small one, was included in a noose of catgut ligature, and the patient made a good recovery. A stone was found in the cortex of the kidney and removed.
Nor are the principles of treatment in the case of gunshot wounds of the abdominal parietes involving a kidney materially different from those just referred to. The wounds are usually associated with more or less damage to surrounding parts such as the liver, diaphragm, and intestines, and are as a rule speedily fatal. Taking some of those in stances of perforation of the kidney by non-explosive bullets where death appears to have resulted from the escape of urine into the peritoneal cavity, rather than from any other effects of the injury, a laparotomy with removal of the kidney would seem to be the only expedient at all likely to be successful. Some years ago, before ab dominal surgery was developed, I remember seeing a youth who had been shot in the back accidentally by a playmate with a small pistol bullet not much larger than a pea. He died in the course of three days from peritonitis. An autopsy showed that the projectile had perforated the kidney and was lying loose in the peritoneal cavity. Death, I believe, was caused by the flow of urine and blood into the abdomen, and in the present day would have been averted by a lapa rotomy. The difficulties, however, arising out of the circumstances under which lesions of the kidney of this grave character are attended will frequently be found insuperable, but here and there a case will occur where life may be saved by prompt surgical interference. Care ful and judicious exploration of the wound in cases of doubt and danger is, however, to be commended.