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the neighborhood of the injured kidney is generally associated with the pain and hemorrhage. When the swelling is very marked and diffuse, hemorrhage and urinary infiltration are probably taking place outside the kidney; but if the swelling is more firm and circumscribed than that just described, filling the kidney space, a hemorrhage inside the capsule of the kidney may be suspected.

Ecchymoses are likely to form on the surface of the body at the seat of the traumatism. At times these do not appear until several days after the injury has taken place. If they appear in the lumbar or inguinal region, they are believed to possess some diagnostic value. The urinary secretion is frequently disturbed, the quantity of urine excreted being probably diminished. Ureter catheterization is a valuable aid in determining the seat and extent of the injury. Recovery is usually rapid from the injury when the kidney surface has not been torn through. Even when the parenchyma has been torn, the kidney manifests a tendency toward repair. In the gravest cases death from internal hemorrhage or shock is likely to be immediate. In mild injuries the pain disappears and the trifling hemorrhage ceases in about forty-eight hours. In severer cases the hemorrhage is more extensive, there is a marked diminution in the quantity of urine excreted, and a swelling is apt to appear in the lumbar region. When the contusion is extremely severe, the kidney may be so lacerated as to resemble a pane of glass through which a stone has been thrownthere are fissures running in all directions. Such severe injuries are almost invariably fatal. Injuries of the kidney, if not too extensive, have a tendency to heal spontaneously, but often manifest unpleasant after-effects. It is possible that an injury to the kidney so slight as almost to be overlooked may later give rise to the formation of multiple abscesses, a single abscess, a cyst, or a calculus, or it may serve as the starting-point for a growth of the kidney. There is a tendency on the part of the profession to pay too little attention to the serious after-results of kidney injury.

Injuries of the kidney are not infrequently the cause, particularly in women, of displaced kidney. They are often, through injury to the ureter or the kidney pelvis itself, the cause of a hydronephrosis. Particularly serious are injuries to the kidney if the accident occurs in kidneys that are not in normal state. Neu

man states that he has seen pyonephrosis, pyonephritis, pyocystic kidney, ureteritis, hydronephrosis, and papillary cystoma of the kidney from injury. With the first three conditions he believes gonorrhea to have been the exciting cause, and injury to the kidney the contributing cause. Some very interesting experiments concerning the effect of an injury to one kidney upon the neighboring kidney have recently been made on dogs by Castaigne. Briefly, he found that a renal contusion caused for a time a diminution in the total diuresis and sometimes abolishes it for twenty-four hours or more. That later on the after-effect on the uninjured side from a transmitted lesion of the other side was to cause a condition of sclerosis in the well kidney, intermingled with hypertrophic zones. He seemed to attribute the condition which took place in the well kidney to the effect of the absorption of kidney toxin from the diseased organ. There is considerable clinical evidence which tends to support the views of Castaigne, obtained by him from his experiments on animals. Anuria through some reflex nervous influence following injury to the kidney has been noticed. Also, particularly by the German school of observers, has a form of nephritis, called traumatic nephritis, been noticed to occur several months after an injury to the kidney, the injury apparently being the only causative facThis traumatic nephritis is stated by at least one observer to be a mixture of a parenchymatous and interstitial nephritis; his views are also corroborated by the very valuable work of Beers, of New York, referred to earlier in the article on Tests of the Permeability of the Kidney, his researches tending to show that there was increased functional activity in the better kidney following the removal of a diseased one.

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The prognosis regarding injuries to the kidney should naturally be guarded. Not only should it be guarded as regards the immediate effect of the injury, but for its later after-effects, and necessarily it is often rendered more difficult by injuries to the neighboring organs. Particularly should the prognosis be guarded if there is any previous history of disease in the kidney, an injury naturally tending to make any previous abnormal condition worse.

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The treatment of injuries of the kidney must be varied according to the nature of the case. Not infrequently the shock following injuries to the kidney is so severe that the patient dies, although no other organ was involved; one of the writers saw a case of this kind at autopsy; in suspected injury of the kidney the ordinary treatment for the relief of shock should be therefore instituted. A careful examination should then be made. In a suspected case of injury to the kidney, if the recovery from shock is rapid and blood soon disappears from the urine, the kidney again assuming its functions, little is required beyond rest in bed, the application of an ice-bag to the injured region, and the administration of a urinary antiseptic. The patient should be kept under constant observation, so that operation may be performed at once if untoward symptoms develop. After the patient has so far recovered from the injury as to be able to be up and about, he should not be dismissed from observation, but should be examined at intervals for some period of time, so as to detect any tendency toward the formation of untoward after-effects.

If the hemorrhage continues and a marked swelling appears in the lumbar region, an exploratory incision should be made and the field of injury carefully inspected. It is best, in doubtful cases, to make an incision and examine the kidney. Such further steps may then be taken as the exigencies of the case would seem to indicate. Particularly should the presence of any tumor in the loin be looked for and observed; it having appeared, it should be watched carefully for a few days, and if no tendency to absorption and no amelioration of the general symptoms have appeared, operative procedures should be instituted. The operation may vary from tampon and suture to nephrectomy, varied according to the conditions found to be present, or which may develop. Nephrectomy should always be the operation of last resort in uncomplicated cases, and in some cases at least, if required, should follow a more conservative operation. The injuries of the kidney offer a particularly good field for conservative surgery. This is borne out by the statistics of Watson in his paper, previously referred to, and very recently other cases have been reported which tend to confirm this view. For instance, Chaput'

1 "Revue de Chirurgie," 1905.

sutured a ruptured kidney which had a fracture extending the entire length of the anterior surface; he put a drainage-tube into the pelvis, and blood passed through the incision for three weeks; hemorrhage then ceased, and perfect cure resulted.

Partial resection of the kidney may be performed upon a ruptured kidney. A. L. Franklin reports a most remarkable case.' A sixteenyear-old girl felt something give way after a fall from a wagon. Pain, vomiting, and hematuria followed; then a state of gradual collapse. Operation eighteen hours after the accident-laparotomy; the left kidney was found torn to pieces, and the right kidney had three transverse tears; the left kidney and three-fifths of right. kidney were removed. Six months later the patient was well and excreted normal urine. Another interesting case has been recorded by Chaput, in which a large portion of the kidney had to be removed following injury, and in a few days the part of the remaining organ was taken out and found to have hypertrophied to a considerable extent. These two cases, narrated above, also tend to demonstrate that the views advanced from experiments on animals are corroborated by clinical observations on man.

146

'Rupture of Both Kidneys," "American Journal of Surgery," 1906.

CHAPTER XIV

RENAL CALCULUS

Under certain conditions stones are formed within the urinary passages. Calculi develop for the most part in the kidney, but they may be found in any of the urinary passages into which they have subsequently entered, where they may either be loose or become encysted.

Pathology-One of the chief causes of the formation of renal calculi is the presence of insufficient fluid in the urine to hold the various organic and inorganic constituents that are normal to it in solution; they therefore become precipitated when the fluids of the urine are reduced and become abnormally saturated with these chemic substances. This condition may arise when the amount of fluids furnished the body is deficient, or when, as in excessive purgation or diaphoresis, the amount of fluid normally excreted through the kidney is diminished. The familiar appearance of calcium oxalate crystals under certain dietetic conditions, or associated with excessive perspiration, is a common example of such a state. The same result may follow when the chemic character of the urine is altered, causing interaction and the precipitation of certain bodies, either normally or abnormally present in the urine. Thus excessive acidity of the urine may cause the precipitation of uric-acid crysta's even though uric acid exist in but normal amounts. In these respects the vital temperature acts very much as heat does outside of the body, tending to prevent precipitation to a certain degree, and to hold the salts in solution better than after the urine has been allowed to cool.

Rainey, Ord, and Carter have shown, by an elaborate series of experiments, that certain bodies in the urine, such as various gums, albumins, and colloidal substances, also tend to cause precipitation of the salts of the urine; these do not, however, appear in a crystalline form, but in a condition that they term submor

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