cases in which the spleen is wounded the diagnosis can easily be es tablished by the location of the external opening and the direction of the track.
As is the case in contusion, there is marked local pain and profuse bleeding, which, if the organ is greatly lacerated, may soon prove fatal. This is apt to occur after gunshot wounds at close range, the organ under such circum stances becoming pulpifiecl. Puncture wounds are less likely to produce fatal haemorrhage.
Kidneys. — The symptoms frequently accompanying wounds of the abdominal organs, extreme pallor, weak pulse, cold extremities, nausea. and vomiting are apt to be most marked when, besides the organ itself, the peritoneum has been pierced.
A wound of the kidney gives rise to severe pain in the majority of cases, but this symptom may be absent. As in cases of laceration, the pain radiates in various directions, especially in the di rection of the external genital organs. The testicle of the corresponding side, besides being the seat of considerable suffering, is frequently raised by spas modic contractions of the scrotum.
At first a small quantity of bloody urine may be passed, but this is often followed by vesical tenesmus and com plete retention, due to the presence of clots in the bladder.
Much information is sometimes ob tained by a close examination of the wound of exit. If the track of the bullet be antero-posterior and the missile have entered from the front and penetrated the kidney, the exit wound will be found in the lumbar region. It is frequently found in this situation to contain urine, a positive indication that the organ or its annex, the ureter, has been wounded.
If the wound of entrance be in the back, its location over the site of the kid ney may suggest a lesion of the latter; but the urine test will only be of value if the projectile only penetrate the kidney without perforating it. If it penetrate the organ, the extravasation will take place into the peritoneal cavity. The same will be the case if the missile enter from the front without going through the organ. Bullets buried in the renal parenchyma either become encysted or cause abscesses, and pass out through the ureters or into the adjoining parts.
Case of gunshot wound of the kidney made evident by the appearance of urine saturating the dressing in the lumbar region. The amount of urine on the dressing gradually decreased, and after about six weeks the sinus had closed. William F. Barry (Med. Record, Mar. 24, 1900).
symptoms vary accord ing to the location of the wound. A perforation between the symphysis and the peritoneum above does not give rise to general symptoms; whereas shock, pallor, weak pulse, vomiting, etc., may be much marked when the peritoneum is involved in the injury. In all cases, however, severe pain is experienced at the site of the lesion and radiating to the thighs and testicles.
The passage of urine soon becomes very difficult and spasmodic. It may be voided, drop by drop, for a long while, notwithstanding the efforts of the pa tient, then suddenly gush out for a few moments and again flow slowly. This symptom may be due to accumulation of clots or to spasm of the urethra. If the catheter is passed, humaturia be comes evident when the bladder has been penetrated: a characteristic sign.
As in the case of rupture due to contusion, infiltration may take place through the wound into the neighboring tissues; any obstacle to the free passage of urine greatly encourages this. Hence the necessity, in all bladder lesions, of keeping the organ as free as possible by the frequent use of the catheter.
Prognosis.—The statistics so far pub lished differ so widely that it is difficult to reach a definite conclusion. It is cer tain, however, that gunshot wounds are more frequently fatal than stab wounds, hut that stab wounds, in which the peri toneum is penetrated, are fully as fatal as gunshot wounds.
Intraperitoneal \rounds of the bladder are uniformly fatal, while extraperito neal wounds gave a mortality of only 15 per cent. Gunshot wounds of the kidney are attended with a death-rate of 44 per cent. In gunshot wounds of the liver the mortality is 26.8 per cent. Wounds of the spleen are difficult to diagnose; mortality 65 per cent. Wounds of spinal cord in the lumbar region result fatally. Mortality of wounds of the pelvic bones also very high. Seliger (Prager med. Woch., '92).