REPRINTED EROM 
ANNALS 
OF 
SURGERY 
A MONTHLY REVIEW OF SURGICAL SCIENCE AND PRACTICE 
EDITED BY 
J. WILLIAM WHITE. M.D. 
WILLIAM MACEWEN. M.D, 
L S PILCHER. AM. M D. 
FREDERICK TREVES. F.R.C&, 
ORIGINAL MEMOIRS 
"■ is: ;£EA. - 
TRANSACTIONS OF THE NEW YORK 
SURGICAL SOCIETY. 
"sssipLExsse 
Kl. 
TABLE OF CONTENTS. 
EDITORIAL ARTICLE. 
INDEX OF SURGICAL PROGRESS 
''3''.??^ 
BOOK REVIEWS. 
ANNOUNCEMENTS 
UNIVERSITY UF PENNSYLVANIA PRESS. 
PHILADELPHIA. PA 
Great Britain : Cassel! and Company. London. 
Ramolc Nnmber, 50 Ceata. 
DECEMBER, 1886 
Single Copies, Two Shilling*. 
TWO CASES OF PERFORATING GUNSHOT WOUND OF 
THE KIDNEY. 
By MAURICE H. RICHARDSON, M.D., 
OF BOSTON, 
Surgeon to the Massachusetts General Hospital: Assistant Professor of Clinical Surgery, 
Harvard Medical School. TWO CASES OF PERFORATING GUNSHOT WOUND 
OF THE KIDNEY.1 
BY MAURICE H. RICHARDSON, M.D., 
OF BOSTON, 
SURGEON TO THE MASSACHUSETTS GENERAL HOSPITAL; ASSISTANT PROFESSOR OF 
CLINICAL SURGERY, HARVARD MEDICAL SCHOOL. 
CASE I. Penetrating Gunshot Wound of the Abdomen; Per- 
foration of Kidney and Liver; Exploration; Nephrectomy; 
Death.-G. W. L., aged thirty-four, was shot in the abdomen 
on December 13, 1894, with a revolver of 32-calibre, which was said 
to have been held in contact with the body by the assailant, who was 
standing directly in front of him. As the victim was trying to escape, 
a second shot was fired, which took effect in the back of the right 
shoulder. The patient was brought to the Lynn Hospital (service of 
Dr. Pinkham), and fourteen hours after the accident was first seen by 
me in consultation with the hospital staff. 
The chief symptoms were vomiting and abdominal pain. The 
pulse was 98, not strong ; the temperature 100.20 F. The abdomen 
was rigid; the abdominal muscles, especially the recti, standing out 
prominently. There was some distention of the epigastrium, but no 
especial tenderness anywhere in the abdomen. The countenance was 
pale and anxious. 
One and a half inches to the left of the median line, and three 
and a quarter inches above the umbilicus there was a penetrating 
gunshot wound surrounded by an area of ecchymosis. The 'bullet 
could be felt under the skin, behind the right kidney, near the lum- 
bar spines. The right kidney had evidently been wounded, but it 
was plain that the internal haemorrhage, if any existed, was not 
severe. The rigidity of the abdomen, the vomiting, and the epigas- 
tric distention indicated some serious abdominal complication. 
1 Read by title at the meeting of the American Surgical Association, May, 
1896. T T Yi*Tk a 2 
MAURICE H. RICHARDSON 
Though the rate of the pulse was not high, the quality was poor. 
The temperature, as in most abdominal cases, had little bearing upon 
diagnosis, prognosis, or treatment. The general condition of the 
patient, with tfie local signs-especially the abdominal rigidity- 
seemed to demand immediate exploration. Moreover, the bullet, 
if its course was a straight line between the point of entrance and 
the spot where it could be felt under the skin, could hardly have 
failed to strike either the transverse colon, the stomach, or the duo- 
denum. Furthermore, the haematuria showed clearly that the kidney 
had been injured. In view of these considerations it was thought 
best to open the abdomen at once. 
A short median incision above the umbilicus showed that there 
was free blood in the peritoneal cavity; that the anterior wall of the 
stomach was uninjured ; that the transverse colon and left kidney 
were intact; and that there had been no faecal extravasation. The 
incision was then enlarged sufficiently to permit examination of the 
small intestines, which also were found to be uninjured. The thor- 
ough examination which the extended incision made possible showed 
an infiltrating retroperitoneal haemorrhage about the pancreas. In 
the mesentery of the transverse colon there was considerable haemor- 
rhagic extravasation. The dependent regions of the abdominal cavity 
were filled with fluid blood. Further exploration demonstrated clearly 
that there had been no injury to the stomach or the intestines; to the 
pancreas or the spleen. 
It having been ascertained beyond a doubt that the stomach and 
the intestinal tract were unharmed, that there had been no faecal ex- 
travasation, and that no serious haemorrhage was going on, the right 
kidney was exposed. Near the hilum a ragged opening was found, 
which admitted the tip of the finger. From the hilum the course of 
the bullet was directly across the cortex to the convex border, where 
it had emerged and had become lodged under the skin. The renal 
vein as well as the pelvis of the kidney had been extensively lacerated. 
Very little if any blood was escaping. It seemed clear that the vital- 
ity of the kidney had been destroyed (see Fig. i). Nephrectomy was 
immediately decided upon. 
The kidney was easily enucleated and removed after its vessels 
had been tied with silk. The abdominal cavity was carefully cleansed 
with dry sterile gauze. The patient's pulse continued fair, though 
weaker than at first. At the very close of the operation the course of 
the bullet was discovered. There was a wound of entrance in the PERFORATING GUNSHOT WOUND OF THE KIDNEY. 
3 
anterior surface of the left lobe of the liver. The bullet had per- 
forated this lobe, had next ploughed a furrow in the quadrate lobe, and 
finally had struck and pierced the kidney, as previously described. 
In the dorsal decubitus the wound of entrance in the liver was at 
least four inches higher than the point where the bullet had pierced 
the peritoneum of the anterior abdominal wall. Far from injuring 
the transverse colon, the duodenum, or even the stomach, the bullet 
had passed entirely above them ; it had not even traversed the free 
abdominal cavity, except as it passed from the anterior wall directly 
into the liver, being practically in liver or kidney substance through- 
outfits course. 
Fig. I.-Perforating gunshot wound of kidney; appear- 
ances presented by the kidney removed in Case I. 
No blood was escaping from the wounds in the'liver. The ab- 
dominal incision was closed without drainage. The bullet was 
removed from its place of lodgement by a small incisionJthrough the 
skin of the back. 
The patient stood the operation well, suffering comparatively 
little shock. On the following day he was reported as much better ; 
urine was secreted by the other kidney in small amounts; the out- 
look seemed good. The second twenty-four hours brought unfavor- 
able symptoms. The abdomen became distended ; the pulse and 4 
MAURICE H. RICHARDSON. 
temperature rose; the patient began to vomit. He died forty-four 
hours after the operation and fifty-eight from the time of injury, hav- 
ing secreted twenty-five ounces of normal urine. 
On December 21, Dr. Pinkham wrote, " L. began to fail notably 
at noon, Saturday. At 4 p.m., Dr. Stevens and myself examined into 
his condition, and decided that he could not live. We informed 
him, in order that he might make a statement that could be used in 
court. At this time his mind was clear. There was sufficient pain 
to require the use of opiates. The pulse was quick and compressible 
at 117. Respiration was 50 to 60, with abundant tracheal rales. 
The abdomen was distended and rigid. He had been vomiting, 
and nausea was manifest when water was taken. The pain was 
chiefly in the back. I was inclined to think that these symptoms 
were due to sepsis, and that the man died promptly when they 
supervened, because he was weak from shock and haemorrhage. 
The wound of the liver which we saw was, as you surmised, in the 
left lobe. The course of the bullet, as shown by the autopsy, 
was as follows : through the abdominal wall and the left lobe of 
the liver about three-quarters of an inch from the anterior mar- 
gin, and an inch from the longitudinal fissure; thence diagonally 
across the lower portion of the quadrate lobe (making a furrow) ; 
thence through a projecting portion of the right lobe near the middle 
of its under surface; thence through the kidney and out between the 
eleventh and twelfth ribs. The left kidney appeared unchanged at 
the autopsy. Everything connected with the operation was in good 
condition. There was no sign of pus. The omentum majus and the 
peritoneal covering of the transverse colon were injected and dark in 
color. The retroperitoneal extravasations were very dark ; elsewhere 
the peritoneum appeared healthy. The liver did not seem to be 
swollen, but on section it was slightly grayish in color. There was 
considerable (perhaps a pint) free liquid-dark-colored blood or 
very bloody serum-in the peritoneal cavity. In the right pleural 
cavity was some very bloody serum,-about two ounces. In the left 
pleural cavity an equal quantity of light red serum. Lungs healthy 
in color and not congested." 
There were no gross appearances of sepsis. 
Nephrectomy seems proper and even necessary in cases of 
violence in which the kidney is so lacerated that its functions 
cannot be maintained, especially if the peritoneal cavity is in- PERFORATING GUNSHOT WOUND OF THE KIDNEY. 
5 
volved and liable to contamination. If the course of the bullet 
is such that the peritoneum is uninjured, there being, therefore, 
no necessity for abdominal exploration, haste is not imperative, 
and the patient may consequently be watched for symptoms 
which may indicate the next step. When a kidney, lacerated by 
a septic missile is pouring urine into the abdominal cavity, the 
necessity for exploration seems manifest. If the secretory power 
of the kidney is not destroyed, and if the pelvis and ureter are 
still intact, some more conservative procedure than extirpation 
may be selected. Even under these more favorable conditions 
it may at times be better surgery to remove entirely the cause of 
possible sepsis than to endeavor by palliation to save a weakened 
kidney at the expense of great danger to life. 
The foregoing remarks were written not long after the re- 
ceipt of Dr. Pinkham's letter. The question of saving a kidney 
that had been the seat of a perforating gunshot wound never 
again presented itself to me clinically until the occurrence of the 
second case (March 25, 1896), though it was often a subject of 
discussion. At least two cases of gunshot wound of the kidney 
had been treated previously at the Massachusetts General Hos- 
pital, both complicated by perforations of the intestine, and both 
fatal. In the absence of such complications the advisability of 
nephrectomy in gunshot wounds of the kidney seems easier to 
decide. A kidney the vitality of which is destroyed by lacera- 
tion of its artery or its vein should be removed. Is it also im- 
perative to remove a kidney which is so perforated that urine 
escapes into the peritoneal cavity ? It seems to me that the 
answer should be in the negative unless the circumstances are 
exceptional; for the harm caused by the extravasation of urine 
presumably healthy has already been done, and although thor- 
ough drainage is essential nephrectomy does not materially pro- 
mote it. Moreover, by guiding the urinary stream out through 
the wound of exploration a kidney may often be saved, not only 
to carry on its functions, weakened though they may be, but 
also to repair its injuries by spontaneous closure of the renal 
wound. Furthermore, a laceration involving even a considerable 
portion of the secreting substance of the kidney may be treated 6 
MAURICE H. RICHARDSON. 
by resection of the injured tissues with suture, a method of treat- 
ment which seems highly commendable in suitable cases. In 
the event of a permanent urinary fistula efforts at artificial repair 
may be made, or a subsequent nephrectomy~may be performed. 
Case II.-Penetrating Gunshot Wound of the Abdomen; Per- 
foration of Kidney and Liver; Exploration; Drainage of Kidney; 
Recovery. On March 25, 1896,1 Daniel M., aged thirty-two years, 
was brought to the Massachusetts General Hospital, having been shot 
at a dog-fight two or three hours before while trying to escape from 
the police. 
Examination showed a well-developed man. There was marked 
pallor; the pulse was 90, weak ; the temperature was 990 F. (by 
rectum); the respiration 28, labored. The patient was restless and 
complained of pain in the epigastrium. The abdomen was rigid, 
especially over the right upper quadrant, where it was also tender. 
There was neither vomiting nor expectoration. Urine withdrawn by 
catheter contained blood. Consciousness was unimpaired. There 
was a bullet wound of entrance five inches from the lumbar spines, 
on the right side of the back, on a level with the anterior superior 
spinous process of the ilium. The bullet could be felt under the 
skin just below the right anterior superior spine. It was removed 
and proved to have a calibre of 32. 
A second wound of penetration was found in the back, on the 
right side, at the level of the umbilicus, three inches from the spine. 
The direction of the wound was upward and forward, and from it 
there was a slight haemorrhage. 
The patient's distress was conspicuous ; respiration was hurried, 
shallow, labored, and noisy; the hands and feet were cold. Per- 
cussion and palpation caused pain. That the right kidney had been 
injured seemed clear; that there was more or less internal haemor- 
rhage, certain ; that the intestines had been perforated, probable ; 
that there was necessity for exploration, unquestionable. 
A vertical incision, nine inches long, was made from the margin 
of the ribs to the crest of the ilium. The line of incision was 
parallel to the right linea semilunaris and two inches or more pos- 
terior to it. This incision permitted free inspection of the right 
half of the abdomen,-of the small intestine, the right kidney, the 
1 Massachusetts General Hospital Records, Vol. cccix, p. 51. PERFORATING GUNSHOT WOUND OF THE KIDNEY. 
7 
liver, the gall-bladder, the duodenum, and the pylorus. It per- 
mitted also thorough manual exploration of the whole abdominal 
cavity. 
A large amount of free blood was found in the abdomen, and 
an infiltrating haemorrhage in the perinephric and retroperitoneal 
tissues. No intestinal wounds could be detected. The first evidence 
of gunshot wound that was discovered in the abdomen was a perfora- 
tion in the under surface of the right lobe of the liver. This open- 
ing was ragged and admitted the tip of the index-finger. Its direc- 
tion was upward and towards the left; there was no bleeding from it. 
The capsule of the kidney was next opened and found to contain 
clotted blood in considerable amounts. This was removed. It was 
now evident that there had been a serious lesion of this kidney. 
The abdominal wound was therefore enlarged by a cut beginning in 
its centre and passing directly backward towards the spine, as far as 
the vertebral aponeurosis. This enlargement of the wound enabled 
me to ascertain exactly the damage done the kidney. The bullet had 
perforated the muscles of the back, had struck the right kidney in the 
centre of its anterior surface, half-way between the hilum and the 
convex border; thence it had passed upward, backward, and inward, 
emerging on the posterior surface about an inch higher than the level 
of the penetration ; thence it had passed into the liver and probably 
through the diaphragm into the right pleural cavity. The pelvis and 
the great vessels of the kidney were uninjured. 
Most of the house-staff were in favor of immediate nephrectomy. 
Conservative treatment was finally adopted, however; first, because 
the vitality of the kidney was shown by visual and by digital ex- 
amination to be unimpaired; secondly, because a large proportion 
of active secreting structure remained intact, and, thirdly, because 
the haemorrhage could be easily controlled. 
The free blood was removed from the abdominal cavity as thor- 
oughly as possible by means of dry gauze. Small strands were 
placed in both anterior and posterior wounds of the kidney and 
brought out of the lower angle of the transverse incision. The ver- 
tical and transverse incisions were closed. The gauze began imme- 
diately to suck out urine and blood. 
For the next twenty-four hours the patient was in fair condition. 
The urine, which he passed in abundance, contained much blood. 
On the fourth day he developed pneumonia in the right side, 
but the wound and the kidney were both doing well. The sterile 8 
MAURICE H. RICHARDSON. 
gauze was all removed on the sixth day, and the sinus was packed 
with iodoform gauze. 
Four weeks after operation the patient was practically well. 
The wound had entirely closed. The urine for a time was bloody; 
then purulent, finally clear and normal. 
The patient was discharged well on April 30, 1896. 
The two injuries recorded in the foregoing pages closely 
resemble each other in most of their essential features. In both 
the weapon and the missile were the same. In both the liver and 
kidney only were perforated ; there was a moderate amount of free 
blood in the abdominal cavity; there was free retroperitoneal 
bleeding; the patients' general condition was the same. In both 
the body of the organ was completely perforated and a portion 
of its secreting tissue destroyed. In both an extensive, explora- 
tion preceded local measures. In the renal lesion they differed, 
however, to an extreme degree. \ In one the vein and the 
pelvis were hopelessly lacerated ; in the other they were intact. 
In one a nephrectomy was resorted to, in, the other simple 
drainage. In the former death ensued, in the latter, recovery. 
The essential difference, therefore, lies in the nephrectomy, 
which the more serious lesion rendered necessary in the first 
case. Had it been possible to preserve what remained of this 
kidney would not the result, to a reasonable certainty, have been 
different ? 
The autopsy showed an absence of the usual signs of sepsis. 
If sepsis caused death the patient must have succumbed in the 
very beg nning of the ptomaine absorption, long before the germ 
colonies had time to show themselves in altered appearances ot 
the peritoneum. In point of fact the autopsy showed that 
" everything connected with the operation was in good condition. 
There was no sign of pus. . . . The peritoneum appeared 
healthy." The left kidney was unchanged to the naked eye. 
Assuming that death resulted in this case from the inability 
of the remaining kidney to carry on successfully the work of 
excreting urine-the most frequent cause of death after the re- 
moval of an active kidney-one cannot but wonder whether the 
injured kidney might not after all have been saved; whether it would not have been better simply to drain the kidney in the 
hope that even if too badly hurt for ultimate recovery, it might, 
for a time do some of the work of excretion pressing so heavily 
on the other side; whether gangrene would surely follow lacer- 
ation of the renal vein, and whether the well-known anomalies 
of the great vessels of the kidney might not justify the hope 
that in some way the vitality of the organ might be kept up ; 
whether, finally, it would not be better on the whole to treat 
conservatively all wounds of the kidney, even the most exten- 
sive. Questions like these have been suggested by these two 
cases. They can be settled only by additional experience. 
PERFORATING GUNSHOT WOUND OF THE KIDNEY. 
9